SF Assessment and Intervention: Supine 3-6 Months

Importance of supine assessment

Spending time in supine when awake, active and moving is important for infant development as this is the first position that infants can independently explore the environment and learn to stabilize the trunk to allow for more differentiated and goal directed movements of the limbs.

Observation of the infant's abilities in supine provide valuable insights into the the different aspects of behaviour that influence present behaviour:: level of alertness, general level of activity, motivation to move, approach/avoidance behaviours, attention and persistence, and engagement with social and physical environment.

Lying supine, especially if the trunk is slightly raised, provides an opportunity for infants to look towards interesting events in the environment.

Infants also learn to reach for and pick up toys that are placed within easy reaching distance.

Before you start
1 The first step is to listen to the parent's views of their infants' abilities in supine.

2 Explain purpose of assessment: to identify the infant's abilities, especially strengths, and explore ways to enhance the variability and complexity of the infant's actions in ways that will promote progress along the developmental pathway and towards identified goals.

Assessment is an opportunity for parents to gain insight into their infant's abilities, the factors that enhance and constrain progress towards goals and identify ways to enhance perceptual motor learning and social interaction.

3 Explain the process: observation, adaptation, planning learning opportunities and practice sessions

Observation: he infant's actions are first observed to identify abilities, strengths and difficulties and atypical movement patterns.

Adaptation of environment:  trying different adaptations to the environment to encourage the infant to become more active, produce more complex and variable movements, and explore different ways of moving and interacting with the environment.

Discovery of goals: parents are encouraged to use insights from observation of infant's strengths and abilities and responses to adaptations in the environment to formulate goals for intervention.

Collaborative planning, during or at the end of the session. Parents and therapist together figure out ways to incorporate learning opportunities into daily routines and dedicated practice sessions.

Observation 
Let the infant lie on a firm surface. It is best to observe the infant wearing only a nappy/diaper and thin layer of clothing, if possible with the limbs exposed. If the room is warm enough and the caregivers have no objections, let them remove all other clothing. Some infants get upset when their clothes are removed, so it may be that you have to compromise on the clothing.  

Posture and movements of the head and and neck
By 3 months infants will usually have learned to maintain the head in the midline, especially when looking at an interesting event or object. 

Will 16w supine momennts of relative repose 1.jpg   

Infants turn head through full range to look towards and event or object. 

Will 31w supine 1.jpg

Head on neck flexion is seen when looking down. 

Will 18w supine quiet moments 14.jpg    

Typical  Observed
Lies with head in midline most of the time   Yes 
Head-on-neck flexion present  Yes
Head turned some of the time - especially when looking at an event in the environment   Yes 
Atypical   
Keeps head turned to one side most of the time  Right    Left 
Maintained midline position of the head  not observed  Not observed 
Infant's head rotation is strongly associated with fencing posture of the UEs Yes 

Posture of the upper extremities during periods of relative quiet
Infants display a range of different postures of the upper limbs when lying supine.
►  When at rest  the infant will usually lie with the shoulders in abduction with variable amounts of lateral rotation and elbow flexion (Bly 1994). 

Will 10w supine repose momennts 1.jpg    Will 10w supine repose momennts 6.jpg   Will 10w supine repose momennts 7.jpg

►  Infants also often bring the hands to the midline and to the face and mouth.​

Hands together and to midline 

  Will 14w supine repose momennts 3.jpg  W 18w look at hands.jpg 

Hands to mouth and face 

      W 18w hands to mouth.jpg   W 18w hands to forehead 1.jpg

►  The hands are often loosely flexed, but  open hand postures and isolated movements are also present. 

W 14 w supine shoulders adducted.png   W 14 w supine hand contact open hand 2.jpg   

Typical Observed 
S abd with some lat rot, E flex or ext, wrist straight.  R    L
Hands lifted to midline R    L
Hands to face and mouth  R     L 
Fingers are lightly flexed Yes 
Isolated finger movements and different hand posture observed  Yes 
Atypical   
S add with upper arm positioned close to the torso, E ext and W flexion R   L
S add with E flex FA pronation, W flex R   L
S abd, lat rot with E flex R   L
Hand fisted  R    L
Thumb in palm  R    L 
   

Trunk posture and stability 
By 4-5 months infants usually lie with spine straight and the pelvis level and have learned to stabilize the trunk in the midline when moving the extremities.

Small range lateral movements of the trunk are observed – this postural sway provides the brain with the proprioceptive feedback it needs to regulate trunk posture and stability.

Observe trunk symmetry and lateral flexion (lateral pelvic tilt) as well as small range lateral oscillatory movements of the trunk (postural sway).  

Typical  
Trunk symmetrical most of the time  when not moving extremities  Yes
Trunk steady when moving extremities: kicking, reaching  Yes 
Pelvic lateral tilt observed some of the time when moving extremities (before 4-5 months) R   L  
Small range lateral displacement of the trunk is observed (postural sway) Yes 
Atypical  
Pelvis tilt with trunk lateral trunk flexion present  R   L 
Trunk rotated back on one side  R   L 

Lower extremity posture when not actively kicking 

►  Hips and knees may be extended or in varying degrees of flexion with the feet resting on the support surface (SS).

Will 10w supine repose momennts 6.jpg    Will 10w supine repose momennts 9.jpg   

►  Hip flexion with knee flexion or extension observed from 4-5 months.

Will 10w supine repose momennts 8.jpg

►  Infants also start to bring hands to knees and feet.  This action is associated with posterior pelvic tilt. 

►  When lying with one foot on the SS the infant may push down and at the same time extend the hip with forward rotation of the pelvis. 

►   Bridging, lifting the buttocks up off the SS, is also seen. 

Will 16w supine push down 1 foot 2.jpg           

Typical Observed 
H and K of one LE extended with varying degrees of plantarflexion.  L   R 
H and K  flexed with foot resting on the SS Yes 
Bilat H and K flexion with feet lifted up off the SS Yes 
Bilat H and K flex with K ext- 4-5 months plus  
Atypical  
H ext with H add and K ext R   L 
Hip flex, add and lat rot with K flex R    L 

Supine LE H add.jpg               Supine H add right .jpg              Supine LE posture hip abduction.jpg

Kicking 

Infants at this age, when awake and alert, will usually engage in bouts of kicking interspersed with periods of minimal LE activity. 

►  A kicking action consists of H flexion with associated H abduction and lateral rotation and K flexion, followed by H and K extension associated with few degrees H abduction.

Will 10w supine kicking 7.jpg    Will 10w supine kicking 9_1.jpg   Will 10w supine LE ext posterior pelvic tilt.jpg

►  Bilateral kicking actions are also present, alternating between bilateral hip and knee flexion and bilateral hip and knee extension. 

►  Hip, knee and ankle movements are are still coupled  in younger infants. The foot is held in DF with a small decrease in the range of DF when the LE is extended.  The  range of ankle movement increases with age, with more plantar flexion observed. 

Adapted environment 

►  If the infant is not very active, raising the infant's level of arousal by talking to them or providing an interesting object for the infant to look at will usually lead to more kicking actions. 

►  A small bell attached to one ankle will also stimulate more LE activity

Typical  Observed
Kicks actively  Yes 
Adapted environment increases kicking -  voice, bells  
Unilateral single leg kick Right  Left 
Repeated kicking with one LE Right   Left
Reciprocal kicking actions involving both LEs, Right   Left 
Bilateral kicking with both LEs flexing and extending at more or less the same time.  . Yes 
Hip extension is associated with a small range of hip abduction.  Yes 
Pushes down on one foot and extends hip - bridging-one-leg R   L 
Atypical  
LE movements limited - kicking actions not seen  R   L
Kicking movements are not fluent with jerky transitions from flexion to extension R    L
One leg is less active than the other  R    L
Extension of the hip is associated with hip adduction.  R    L 

Upper limb reaching and exploring of surfaces
From soon after birth infants start to reach towards interesting objects that are within reaching distance and also actively explore the environment by  moving  their hands and fingers across different surface, including their bodies, clothing and support surfaces. 

Reach, hold,feel

   Will 23w  supine posture 5.jpg   W 18w reach 3 leg toy 2.jpg   W 18w toy hold and finger.jpg 
Explore clothing, face and other hand 

    W 14 w supine hand to hip.jpg Will 18w supine quiet moments 14.jpg

Typical  Observed 
One and reaches towards/grabs interesting object that is within easy reach  R   L 
Reaches towards/grasps interesting object  with both hands when presented in the midline  Yes 
Reaches towards and grasps object with one or both hands  Yes
Holds object with one hand, uses fingers of other hand to explore object  Yes 
Explores body and clothing with hand  - rubbing, grasping  R   L
Explores surrounding surfaces with hand and fingers  R   L
Explores surfaces with foot  R   L
Foot play: explores other foot   R   L
Atypical  
One hand moves less than the other   
Does not initiate reaching or grasping   
Hand  fisted, thumb in palm   

Rolling 
From the 4-5 month infants start to initiate rolling from supine to prone. At first they roll onto their sides but with practice, persistence they roll all the way into prone. 
Infants find many diverse ways to initiate rolling - there is no right way to do this. 

►  Some infants press down on one foot, extend the hip to rotate the pelvis forwards, with rotation of the chest following.

L 6m CA roll 6.jpg   L 6m CA roll 7.jpg   L 6m CA roll 8.jpg

►  At other times the infant  flex both hips, moves the lower extremities to one side then topple over to the side. 

L 6m CA roll.jpg

►  The infant may initiate rolling by reaching across the body for a toy - often this action is associated with neck and upper trunk flexion. 

Typical Observed 
Rolls from supine to side lying Yes    Partially 
Rolls from supine to prone  Yes     Partially
Pushes on one LE to initiate  Yes
Lifts both LEs to initiate rolling  Yes
Reaches across body to initiate rolling  Yes
Other  Yes
Atypical   
Infant does not roll to side  L   R  
Infants roll part way and then gets stuck  L   R 
   

Adaptations to encourage more complex or new behaviors 

Head and trunk support to increase limb movement 

►  Let the infant lie on a pillow - mold the pillow a little to create a hollow so that the trunk is provided with some lateral support. 

Observe changes in the infant's movement behavior

Will 16w on pillow 4.jpg

►  Roll a soft fleece blanket into a long roll. Let the infant lie with their  head and shoulders on the middle of the roll and tuck the  rest of the blanket in next to the torso. 

Lifting the head and supporting the arms in this way will often assist the infant to lift the hands to the midline and increase hands-to-face actions.  

►  Fold a towel to make a square cushion. Flex the infants hips and knees and position the cushion under the buttocks so that the pelvis is tilted backwards. 

In this position the infant may find it easier to maintain a flexed LE position with the feet lifted up off the SS> 

Adaptations that encourage exploration and engagement 

►  Dangle an interesting toy that makes a noise when jiggled, close to the infant's hand. Briefly jiggle the toy to catch the infants attention.  Wiat for the infant to respond - this may take some time so be patient. 

Infants will often reach for and play with a toy  that is positioned within very easy reach. 

►  Let the infant lie on a support surface that makes a noise when the infant moves.

A plastic carrier bag inserted into a pillow case and positioned under the infant provides an interesting but not too loud noise. 

Movement of the infant's foot on the adapted  SS will provide a novel and interesting sensation and often prompt the infant to start exploring this new SS with the feet.  

►  Attach a small bell just above one ankle to encourage kicking.